DATA PRIVACY: The data that you enter on this form will be stored in REDCap, a secure web-based application for building and managing online surveys and databases. ALL other data related to our research is be stored on secure servers maintained by our research laboratory. If you are uncomfortable entering your information using this form, please read the study information below, and if you are still eligible please contact a researcher by replying to the email that was sent to you to set up a screening phone call.
CONSENT
Screening Protocol for Pain Studies
Principal Investigator Tor Wager
PARTICIPANT INFORMED CONSENT FORM
Part A: Online Screening
V1.0. 1/19/2010
Please read the following material that explains this research study. Signing this form will indicate that you have been informed about the study and that you want to participate. We want you to understand what you are being asked to do and what risks and benefits--if any-- are associated with the study. This should help you decide whether or not you want to participate in the study.
CONTACT INFORMATION
You are being asked to take part in a research project conducted by Tor Wager, Ph.D. a faculty/staff member in the University of Colorado at Boulder's Department of Psychology, 345 UCB, Boulder, CO 803090345. Tor Wager can be reached at 303-492-7487.
PROJECT DESCRIPTION
The goal of the Principal Investigator's research is to gain a better understanding of how pain is processed in the human brain. However, because the studies we conduct in our lab have several important requirements, we use a screening process to make sure that we only recruit people who are eligible to participate. The surveys and questionnaires that you complete in this screening will help us determine whether you are eligible to participate, and if so, which study opportunities in our lab we should contact you about.
PROCEDURES
Taking part in this study is completely voluntary. You do not have to participate if you don't want to. You may also leave the study at any time. If you leave the study before it is finished, there will be no penalty to you, and you will not lose any benefits to which you are otherwise entitled. However, you will not be able to participate in any pain studies in our lab.
Description of Procedures
If you agree to take part in this study, you will answer a short questionnaire online. This will take about 5 to 10 minutes. After you complete the questionnaire, a member of our lab will review your responses. If you are eligible to participate in our pain studies, someone from our lab may then contact you to schedule a time when you can come into the lab. The first time you come into the lab, we will fill out additional questionnaires and do a basic pain test to make sure you are eligible to participate in additional studies. You will receive more information about that part of the study if you are invited to come in to the lab.
Note that agreeing to participate in this online screening does NOT commit you to participating in any other studies; you are always free to refuse any study opportunities we offer you.
Description of What the Survey Measures will Ask About
The survey measures you will fill out as part of this study may ask you about any or all of the following:
• Your contact information
• Your demographic background
• Your medical history, including questions about any history of pain disorders, psychiatric diagnoses, and substance abuse
• Your personality
You are welcome to skip any question you prefer not to answer; however, please note that some questions require a response in order for us to determine whether you are eligible to participate in pain studies. These questions will be marked with an asterisk.
Time Commitment to Complete Research Procedures
Completing the survey measures will take about 5 to 10 minutes.
Research Location
The first part of this screening will take place on the web. If you are invited to participate in lab studies, they will take place at the Cognitive and Affective Neuroscience laboratory, located in the Muenzinger Psychology building on the University of Colorado - Boulder campus.
RISKS AND DISCOMFORTS
The primary risk of participating in this study is a potential loss of confidentiality and/or privacy. As part of the screening, you will be asked sensitive questions about your medical history and any history of illegal substance abuse. Although it's extremely unlikely, please be aware that your answers could potentially be requested by the police or the courts and used against you. We will take thorough precautions to ensure that your data is kept secure, and we will never voluntarily share your responses to sensitive questions with anyone outside of the research team unless legally obligated to do so. However, we cannot guarantee with 100% certainty that your data will remain secure.
BENEFITS
There is no direct benefit to you for taking part in this study. However, your participation in this study, and potentially others, will help us develop a better understanding of the psychological and neural mechanisms underlying the experience of pain.
SOURCE OF FUNDING
Funding for this study is being provided by the National Institutes of Health (NIH). The NIH is a federal agency that requires that data be collected in a form that permits for differences between men and women and races or ethnic groups to be analyzed.
SUBJECT PAYMENT
You will not be paid for the basic online screening, which will take approximately 5 - 10 minutes. Once you complete the basic screening, you may be offered the chance to participate in additional pain studies in our lab. You will be paid separately in cash for each study you participate in (generally between $12 and $25 per hour).
ENDING YOUR PARTICIPATION
You have the right to withdraw your consent or stop participating at any time. You have the right to refuse to answer any question(s) or refuse to participate in any procedure for any reason. Refusing to participate in this study will not result in any penalty or loss of benefits to which you are otherwise entitled, though as noted, we may not be able to determine your eligibility to participate in additional studies.
The investigators reserve the right to withdraw you from the study for reasons that they deem necessary for your safety, or if you fail to comply with study procedures.
In addition to the research to which you are consenting under this study, we are requesting your permission to save your responses to the survey measures, including your contact information, so that we may contact you about other potential study opportunities. In the unlikely event of a security breach, your responses could be linked back to you. However, we will take thorough precautions to ensure that your data is protected, and will never share your data will anyone outside the research team unless legally obligated to do so. Please note that we will remove your data from our database at any time upon request.
Your information will be kept in our database indefinitely. Any future use of this information that is not already approved under this document would have to be approved by an ethics committee, also known as an Institutional Review Board (IRB). The IRB may ask us to talk to you again before doing the research, or it may let us do the research without talking to you again if we keep your information private.
CONSENT
* must provide value
I consent to have my personal information saved for future research studies and so that I may be contacted about pain study opportunities.
I do not consent to have my information saved for future research studies and do not wish to be contacted about pain study opportunities.
CONFIDENTIALITY
We will make every effort to maintain the privacy of your data. Your information will be kept in a secure, password-protected database, and we will not maintain paper records of your participation other than any consent forms you sign (if you visit our lab). Other than the researchers, only regulatory agencies such as the Office of Human Research Protections and the University of Colorado at Boulder Institutional Review Board may see your individual data as part of routine audits.
QUESTIONS?
If you have any questions regarding your participation in this research, you should ask the investigator before signing this form. If you should have questions or concerns during or after your participation, please contact the research coordinator, Dr. Hedwig Eisenbarth at 303-492-4299.
If you have questions regarding your rights as a participant, any concerns regarding this project or any dissatisfaction with any aspect of this study, you may report them confidentially, if you wish to the Institutional Review Board, 3100 Marine Street, Rm A15, 563 UCB, 303-735-3702.
AUTHORIZATION
By clicking "AGREE" below, I indicate that I have read the above about the study or it was read to me. I know the possible risks and benefits. I know that being in this study is voluntary. I choose to be in this study. I know that I can withdraw at any time.
* must provide value
If you complete these screening questionnaires and are deemed eligible to participate in one or more of our studies, a member of our research team will contact you with more information about participation opportunities. Would you like to be contacted?
* must provide value
Yes
No
What is the zip code of your current address?
Email Address
* must provide value
Preferred Contact Method:
How did you hear about this study?
Craigslist Buff Bulletin Paper flyer Other
List the best times to reach you by phone:
Use MTWRF for days followed by hours available (e.g., M 8-10am; WF 9-1pm, 3-5pm)
List blocks of two or more hours that you have available during the week between the hours of 8am and 8pm
Use MTWRF for days followed by hours available (e.g., M 8-10am; WF 9-1pm, 3-5pm)
Date of Birth:
* must provide value
Today M-D-Y
Female
Male
Other
What is your dominant hand?
* must provide value
Right
Left
Both
Ethnicity
* must provide value
What is your current or last occupation?
If you are or were a university student, what is/was your primary field(s) of study?
Are you interested in participating in pain studies?
* must provide value
Yes
No
Have you ever experienced any of the following?
If you do not wish to specify (this is preferred), use the "ONE OR MORE OF THE ABOVE" option
* must provide value
Do you have any other medical conditions which might make you especially sensitive to contact heat?
* must provide value
Yes
No
Do you have any other medical conditions which might make you especially sensitive to contact cold?
* must provide value
Yes
No
Do you have any reason to think that you are especially insensitive to contact pain in general?
* must provide value
Yes
No
Are you currently (within the last week) experiencing an unusual amount of pain?
* must provide value
Yes
No
Have you been a cigarette smoker within the last 5 years?
Yes
No
If you smoke cigarettes, how often?
1/week or less 5/week or less 15/week or less 1 pack/day 2+ packs/day
How much exercise do you usually get?
Choose the option that fits you best
Almost none 1 hour/week 3 hours/week 7 hours/week 14+ hours/week
Do you train competitively in athletics?
Yes
No
fMRI Studies
Entry into the MRI suite will bring you into the presence of a very strong magnetic field. Therefore, we request that you answer the questions so that we can determine whether it is safe and appropriate to allow you into the imaging suite.
Many of the studies in our lab involve brain scanning using MRIs. Participants in these studies are compensated at a rate of about $20/hour; however, the requirements for these studies are more restrictive. Are you interested in participating in MRI studies? If yes, answer questions in this fMRI study section.
* must provide value
Yes
No
Are any of the following true for you?
If you do not wish to specify (this is preferred), just check "ONE OR MORE OF THE ABOVE".
Do you have any of the following implants or items within your body as a result of any prior or recent medical experience?
If you do not wish to specify (this is preferred), just check "ONE OR MORE OF THE ABOVE".
Some IUDs are MRI safe, please feel free to contact our researchers for more information on IUDs to determine your MRI eligibility.
ucbpainresearch@gmail.com
Have you ever worked as a welder or machinist?
Yes
No
Have you ever had metal removed from your eyes?
Yes
No
Are you or could you possibly be pregnant?
Yes
No
If you need vision correction, do you only have glasses (not contacts)?
* must provide value
Yes, I only have glasses, not contacts.
No, I have both glasses and contacts.
I do not require corrective lenses.
Please click Submit to continue to the next short survey.